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Share of Cost (SOC): UB-04 for Outpatient Services1

This section explains how to complete claims for services rendered to recipients who paid a Share of Cost (SOC). The procedure codes used in the following examples are for illustration purposes only and may not be reimbursable to all provider types. Refer to the Share of Cost (SOC) section in the Part 1 manual for an explanation of SOC and how to determine the following:

  • If a recipient must pay an SOC
  • The SOC amount a recipient must pay
  • If the recipient’s SOC is certified for the month

2 – Share of Cost (SOC): UB-04 for Outpatient ServicesOutpatient Services 391

May 2007

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Share of Cost (SOC): UB-04 for Outpatient Services1

SOC Field on ClaimSOC is entered in the Value Codes and Amounts field (Boxes
39 – 41). Value code “23” in the “code” column of the field designates that the corresponding “amount” column contains the SOC. In the following example, the SOC amount of $50.00 is entered as 5000. Do not enter decimal points or dollar signs. Enter full dollar and cents amounts, even if the amount is even. Use only one claim line for each

service billed. Refer to the UB-04 Completion: OutpatientServices

section in this manual for additional information.

This is a sample only. Please adapt to your billing situation.

Sample. Share of Cost Amount in Value Codes and Amounts Field (Boxes 39, 40 and 41).

2 – Share of Cost1

___ 1998

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Billing Multiple ServicesCase Scenario: Three services are rendered to a recipient on

Rendered on Differentdifferent dates. In this case, an outpatient clinic bills Z7500

Dates of Service(room use codes) for a recipient who requires stitches for his cut

hand. The recipient was seen twice on June 2, the first visit to stitch

the laceration and the second visit to repair several stitches that came

loose. The recipient was seen again on June 30 to remove the

stitches.

Dates / Service / Amount / SOC Cleared / Balance
06/02/07 / room use: / $20.00 / $20.00 / 0.00
06/02/07 / room use: / 20.00 / 20.00 / 0.00
06/30/07 / room use: / 20.00 / 10.00 / 10.00
Total / 60.00 / 50.00 / 10.00

The recipient pays his entire $50 SOC and the provider performs SOC clearance transactions for each of the three services through the eligibility verification system. The recipient’s SOC, therefore, is certified and he is eligible for Medi-Cal.

The provider submits a bill to Medi-Cal. Services rendered cost a total of $60. The first two services are not billed to Medi-Cal because the entire charge is paid as SOC by the recipient. The provider bills
Medi-Cal for the last $20 service because the SOC covered only $10 of that charge.

To bill, enter the $20 service fee in the Total Charges field (Box 47).

Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23). Enter the amount of the

patient’s SOC already applied toward the service fee ($10) in the Value Codes and Amounts field (Boxes 39 – 41). Enter value code “23” in Box 39A and the difference between Box 47 and Box 39 ($10) in the Estimated Amount Due field (Box 55).

2 – Share of Cost (SOC): UB-04 for Outpatient ServicesOutpatient Services 391

May 2007

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This is a sample only. Please adapt to your billing situation.

Sample. Multiple Services Rendered on Different Dates of Service.

Box 80: Record KeepingFor record keeping purposes only and to help reconcile payment on

the Remittance Advice Details (RAD), providers may show in the

Remarks field (Box 80) the SOC amount that the recipient paid or

obligated.

2 – Share of Cost1

___ 1998

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Billing Multiple ServicesCase Scenario: Two services are rendered to a recipient on the same

Rendered on Samedate. In this case, a recipient visits the emergency room twice to see

Date of Servicea doctor about recurring chest pains. The outpatient clinic bills Z7502 (room use code).

Dates / Service / Amount / SOC Cleared / Balance
06/18/07 / E.R. and
blood tests: / $95.00 / $60.00 / 35.00
06/18/07 / Second E.R. and blood tests: / 29.50 / 0.00 / 29.50
Total / 124.50 / 60.00 / 64.50

The recipient pays her entire $60 SOC and the provider performs SOC clearance transactions for each of the services through the eligibility verification system. The recipient’s SOC, therefore, is certified and she is eligible for Medi-Cal.

The provider submits a bill to Medi-Cal that includes both same-day services on separate claim lines.

To bill, enter the total services charged in the Total Charges (Box 47).

Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23). Enter the amount of patient’s

SOC applied to this claim in the Value Codes Amount field (Boxes
39 – 41). Enter value code “23” in Box 39A and the difference between Box 47 and Box 39 ($64.50) in the Estimated Amount Due field (Box 55).

2 – Share of Cost (SOC): UB-04 for Outpatient ServicesOutpatient Services 391

May 2007

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This is a sample only. Please adapt to your billing situation.

Sample. Multiple Services Rendered on the Same Date of Service.

RAD Payment SummarySOC claims are reviewed prior to payment. Because the recipient’s SOC is applied by the State to pay the $50 service billed on this claim, it may appear as “Denied” on the RAD (code 022), or with a payment amount of $.00. The other services will appear in the “Approved” category as partially paid. The Medi-Cal allowed amount for this service will be reduced by the remaining SOC amount. RAD code 408 indicates payment was reduced because of patient liability.

2 – Share of Cost (SOC): UB-04 for Outpatient ServicesOutpatient Services

August 2000